IDR Program Information

Before IDR can be initiated, parties must engage in a 30-business-day open negotiation period. Either the provider or the plan may initiate open negotiation by sending a notice that includes contact information for the initiating party.

The regulations require "contact information" generically — an email address and mailing address are sufficient to satisfy this requirement. During this period, parties attempt to reach a voluntary agreement on the out-of-network payment amount.

If the 30-business-day period concludes without agreement, either party has a 4-business-day window to initiate the federal IDR process. This initiation deadline is a critical procedural requirement.

IDR is available for out-of-network payment disputes between healthcare providers (or facilities, or air ambulance services) and group health plans or health insurance issuers. The process applies to three categories of services:

1. Emergency services — provided at any facility, regardless of network status.
2. Non-emergency services — provided at in-network facilities by out-of-network providers.
3. Air ambulance services — furnished by out-of-network air ambulance providers.

Either party may initiate IDR after the 30-day open negotiation period has concluded without agreement. Jurisdiction may vary based on plan type — for example, self-funded ERISA plans and fully-insured plans may be subject to different regulatory frameworks depending on the state.

Federal IDR uses "baseball style" arbitration — each party submits a final offer, and the certified IDR entity selects one offer in its entirety. The arbitrator may not split the difference or modify either offer.

Under Texas Medical Association v. HHS (TMA III, August 2024), the Fifth Circuit vacated the QPA presumption. All statutory factors must now be considered and weighed equally, with no prescribed sequence of analysis. The mandatory factors are:

1. Qualifying Payment Amount (QPA) — one factor among equals, no longer presumptive
2. Training, experience, and quality outcomes of the provider
3. Market share of the provider or plan in the relevant geographic region
4. Acuity and complexity of the items or services
5. Teaching status, case mix, and scope of services (for facilities)
6. Good faith efforts to enter into network agreements during the preceding 4 plan years

Prohibited factors include: usual and customary charges, billed charges, charges that would have applied absent the No Surprises Act, and rates paid under public programs (Medicare, Medicaid, CHIP, TRICARE, VA).

Bifurcated states: Laws governing IDR in bifurcated states — where jurisdiction may be split between federal and state processes depending on plan type — may change from time to time. Providers and payors should consult with a qualified attorney to understand the specific processes and requirements applicable to their local jurisdiction.

Parties may combine multiple qualified items or services into a single dispute — known as "batching" — when a four-prong test is satisfied:

1. Same Provider or Facility — all items must be furnished by the same provider or facility.
2. Same Payor — payment must be made by the same group health plan or health insurance issuer.
3. Similar Condition — items must relate to treatment of a similar condition (see below).
4. 30-Business-Day Window — all items must be furnished within 30 business days of the first qualifying item (or 90 calendar days if a cooling-off exception applies).

Following TMA III (August 2024), the definition of "similar condition" was remanded. CMS has delegated interpretation to individual certified IDR entities, meaning that each entity may apply its own protocol when evaluating whether claims are sufficiently similar for batching.

The "similar condition" requirement for batching may be satisfied by meeting at least one of the following criteria:

1. Services performed within the same patient encounter or on consecutive days.
2. Identical service codes across patients.
3. For anesthesiology, radiology, pathology, and laboratory services: codes falling within the same Category I CPT code ranges.

Following TMA III, the determination of what constitutes a "similar condition" may also consider the substantive medical context of the claim, the economic viability of the claim, and the provider's specialty or sub-specialty linkage. Individual IDR entities may develop their own protocols for evaluating similarity.

A bundled arrangement occurs when a provider, facility, or air ambulance service bills for multiple items or services under a single service code, or when a plan makes payment decisions for multiple items under one code (such as a DRG). Bundled claims are treated as a single determination for purposes of certified IDR entity and administrative fees.

Bundling is distinct from batching: bundling involves different services grouped under a single billing code, while batching involves combining multiple separate claims into a single dispute proceeding.

A 90-calendar-day cooling-off period restricts the same parties from initiating subsequent IDR proceedings for the same or similar items and services after a determination has been issued (45 CFR 149.510(c)(4)(vi)(B)).

The cooling-off restriction is code-specific, not condition-specific. All three of the following conditions must be present for the cooling-off period to apply:

1. Same CPT/service code as the prior determination
2. Same health plan or payor
3. Within the 90-calendar-day window following the prior determination

A different service code — even for the same condition — is not subject to the cooling-off restriction. Similarly, the same code against a different plan is not blocked. During the cooling-off period, the batching window extends from 30 business days to 90 calendar days for items furnished during that period. Claims from before and during the cooling-off period may not be combined.

The complete federal IDR process follows these steps:

Step 1 — Initial Payment or Denial: Plan issues initial payment or notice of denial (30 calendar days).
Step 2 — Open Negotiation: 30-business-day negotiation period between provider and plan.
Step 3 — IDR Initiation: 4-business-day window to initiate the IDR process.
Step 4 — Arbitrator Selection: Certified IDR entity selected (3–4 business days).
Step 5 — Offer Submission: Both parties submit final offers (10 business days).
Step 6 — Determination Issued: IDR entity selects one offer (30 business days).
Step 7 — Payment Due: Non-prevailing party makes payment (30 calendar days).
Step 8 — Appeals Window: Period for error correction requests (90 days).

The total process from initial payment to final resolution typically spans approximately 250–300 days.

Under June 2025 CMS guidance ("Errors Identified After Dispute Closure"), determinations may be reopened in limited circumstances. Errors fall into three categories:

1. Clerical Errors — Typographical mistakes, computational errors, or IT-related processing errors in the determination.
2. Jurisdictional Errors — Incorrect eligibility determination, such as disputes that should not have qualified for federal IDR.
3. Procedural Errors — Failure to properly evaluate timelines, cooling-off periods, batching eligibility, or other procedural requirements.

The error correction process involves a two-step review: the certified IDR entity first validates the claimed error, then CMS determines whether the dispute should be reopened. A 30-day window is available to request error correction after the determination is issued. If reopened, the overall process may be extended by approximately 90 additional days.